A 60 year male with diabetic nephropathy

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Vignatha 9th semester

roll no: 45

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case:

Case: A 60 year old male from tirumalagiri came to the hospital with the chief complaints of pedal oedema, shortness of breath and decresed urinary output since 3 months.

History of present illness: The patient was apparently asymptomatic 3 months ago then he developed bilateral pedal oedema which is painless and is of pitting type. He also had shortness of breath(grade:3) and decresed urinary output which is associated with burning sensation.

Past history: 

•He is a known case of diabetes since 16 years and hypertension.

•He was dianosed with coronary aretery disease and percutaneous transluminal coronary angioplasty was done one and a half year ago.

Personal history: Diet: mixed; appetite: normal; bowels:normal; micturition: abnormal; sleep: adequate; no addictions since 5 years(was alcoholic before).

Family history: insignificant 

General examination: The patient is conscious, coherent and cooperative. He is well oriented to time, place and person.

Built: poor ( muscle wasting over the arms and truncal obesity noticed)

Nourishment: poor 

Pallor: present 

Icterus: absent

Cyanosis: absent 

Clubbing: absent 

Lymphadenopathy: absent 

Vitals:

Temperature: afebrile

Pulse: 82 beats per minute

Respiratory rate: 20/ min

Blood pressure: 140/90 mmhg

Systemic examination:

CVS: s1 and s2 heard

RESPIRATORY SYSTEM: No dyspnoea, no wheeze, position of trachea: central, breath sounds: vehicula.

ABDOMEN: 

                     No tenderness

                    No palpable mass 

                    No free fluid

                   Liver: not palpable

                   Spleen: not palpable 

                  Bowel sounds: heard

CNS: conscious 

          Speech: Normal

          No neck stiffnes 

        Normal cranial nerves, motor and sensory system.

INVESTIGATIONS 

Complete blood picture

Blood urea

Serum creatinine 

Serum iron

Seum electrolytes

HBsAg

Anti HCV antibodies

 

ECG

Provisional diagnosis

•Diabetic nephropathy on MHD 

•Known case of coronary artery disease and PTCA was done.

Treatment:

Inj. Lasix 40mg 

Tab. Ecosprin 

Tab. Nitroglycerin 2.5mg

Tab. Nodosis 500mg

Tab.OroFGR XT

Inj. Erythropoietin 400IU SC weekly twice 

Fluid restriction <1.5 L/day

Salt restriction <4gm/day